This review is a convenient reference and follows the “mainstream” recommendations. Note that the A1C target of 7%, which the authors advocate, is controversial number..
Showing posts with label Diabetes. Show all posts
Showing posts with label Diabetes. Show all posts
Medical management of T2DM
July 7, 2009
What's going on with diabetes
January 23, 2009
VADT is yet another negative trial showing a lack of benefit from controlling blood sugars.
That makes three negative trials in the last 12 months.
ADVANCE trial: 11,140 people randomized to gliclazide in order to lower the A1c to 6.5, the control group achieved 7.3%. This lowered combined micro- and macrovascular complications by 10% 18.1% vs 20% after a median of 5 yrs (p=0.01). However the difference was entirely driven by a 21% reduction in nephropathy, with no reduction in retinopathy, macrovascular complications or reduction in CV death or death from any cause.
ACCORD Trial: 10,251 people randomized to usual care (A1c 7.0-7.9) or intensive care (A1c under 6%). There was no difference in the primary composite outcome of non-fatal heart attack and strokes and CV mortality. Unfortunately there was a significant increase in total mortality (p=0.04) with high mortality in the intensive therapy group.
All three of these trials were looking to prove that better glycemic control could reduce strokes and heart attacks. We have known since the early nineties that good glycemic control prevents or delays microvascualr complications (kidney disease, blindness, neuropathy) but the data on cardiovascular disease was lacking. This is important because relatively few diabetics develop ESRD and most patients die of heart disease, a macrovascular complication. For example in type 1 diabetics the 20 year risk of developing ESRD is only 2.2%, while the risk of death is four times that at around 10%.
Unfortunately, this looks like a bust. Not one of the trials have shown any sign that improved glycemic control translates into reduced heart attacks or strokes
Hyperglycemia management updated-2009
January 6, 2009
The statement, produced jointly by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), recommends that if target glycemic goals are not met with initial lifestyle interventions and metformin, rapid transition to new regimens should be initiated.Read this PDF article..
Skin signs in DM
December 16, 2008
Patients with type 2 diabetes more often develop skin infections, whereas those with type 1 more often have autoimmune-related lesions.Read more..
Thiazides and Diabetes
November 29, 2008
Thiazides use in treating hypertension is on the increase. Dibetogenic potential of thiqazides is well known over 25 years. Read this article that discuses the recent changes in guidelines. Read More..
Glycemic Burden
November 12, 2008
In order to develop strategies that optimally address the glycemic burden in type 2 diabetes, it is informative to understand the relative contributions of FPG and PPG. Monnier et al did just that in a study published in 2003.
They enrolled 290 non-insulin- and non-acarbose-using patients with type 2 diabetes. Their plasma glucose concentrations were determined at fasting and during postprandial and postabsorptive periods. The areas under the curve above fasting glucose concentrations and above 6.1 mmol/L were calculated for further evaluation of the relative contributions of postprandial and fasting glucose increments to the overall glycemic burden.. The data were analyzed by quintiles of A1c.As shown in the Figure, the relative contribution of PPG decreased progressively from the lowest (69.7%) to the highest quintile of A1c
T2DM Management Update
October 25, 2008
This Update is published on line in Diabetic Care..Read more.
Surgical Cure for T2DM
October 10, 2008
Time has coe to consider surgery as cure for T2DM and metabolic syndrome. This is called Metabolic Surgery borrowed from Bariatric Surgery.This surgery is kind of "Neuroendocrine Break" This is done laproscopically and involves creating a sleeve gastrectomy and then linked to Ileum. This procedure promotes reduced secretion of Gastric Ghrelin and reduced appetite. GLP1 and GIP levels increase and this causes increased Insulin levels with reduced Glucagon levels.Success rate is over 90% and patients with BML less than 30 can be operated..
Read published articles..
Read published articles..
Assessment of Diabetic Foot- Foot Protocol
A simple protocol can be used to assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.
The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J.M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.
The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.
Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.
Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:
▸ Vibration using a 128-Hz tuning fork.
▸ Pinprick sensation.
▸ Ankle reflexes.
▸ Vibration perception threshold testing.
Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).
Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.
Subsequent therapy and follow-up care should be provided according to the category assigned: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.
The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J.M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.
The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.
Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.
Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:
▸ Vibration using a 128-Hz tuning fork.
▸ Pinprick sensation.
▸ Ankle reflexes.
▸ Vibration perception threshold testing.
Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).
Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.
Subsequent therapy and follow-up care should be provided according to the category assigned: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.
New Diabetic guideline for Canada
September 26, 2008
The Canadian Diabetes Association has released new clinical practice guidelines to emphasise the importance of early identification of risk factors in the prediabetes stage in order to prevent the onset of diabetes and the aggressive management of those risk factors in order to prevent the serious complications associated with the disease.
Select Recommendations
· Early identification and treatment of risk factors for diabetes-related complications such as cardiovascular disease, kidney, and eye disease is essential through proper disease management to avoid serious complications.
· The Guidelines are now recommending that people with diabetes who are at risk for developing heart disease be aggressively treated to lower low-density lipoprotein (LDL) cholesterol to <=2 mmol/L. This lower level, in combination with strict blood pressure control, is proven to help substantially reduce heart disease and stroke. · People with diabetes are encouraged to perform resistance exercises in addition to moderate to vigorous aerobic exercises, such as brisk walking. · Adults with diabetes should consume no more than 7% of total daily energy from saturated fat and should limit intake of trans fatty acids to a minimum..
Full guideline is avialble as PDF format at CDA site..
Endo Barrier for T2DM
September 21, 2008
This interesting device that can be inserted through an endoscope has been devised. No need for bariatric surgery..<>READ THIS STUDY REPORT..
Ocular associations of DM
September 17, 2008
Diabetic Retinopathy is the most well known ocular complication of Diabetes mellitus. Associations other than retinopathy are known and <>read more to learn about them..
Treat Glucose Early
September 13, 2008
Ten-year posttrial monitoring from the landmark United Kingdom Prospective Diabetes Study (UKPDS) indicates that a strategy of early intensive glucose lowering, either with a sulfonylurea or metformin, has lasting, significant effects not only on major diabetes end points but also on risk of myocardial infarction (MI) or all-cause mortality. One of the "most plausible" theories as to why the recent Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes and Vascular disease (ADVANCE), and Veterans Administration Diabetes (VADT) trials showed no benefit of glucose control on cardiovascular outcomes was that the glucose control was too late and could not "stop the moving train."By contrast, blood-pressure benefits seen with "tighter" blood-pressure lowering in 1997, when the trial first concluded, were not maintained over time.
Read more of this original article published in NEJM..
eAverage Glucose
September 5, 2008
Next, another straight forward report, this time on diabetes. David Nathan et al from the Joslin Diabetes Center reported in the August 31st issue of Diabetes Care, their study “Translating the A1C Assay into Estimated Average Glucose Values.” Their study essentially defines the mathematical relationship between A1C and average glucose. The obvious and practical need for this is obvious: patients understand “average glucose” much better than a number that tells them the “amount of hemoglobin that is glycosylated.” How many times have you found yourself explaining exactly what HgA1C means only to have a patient respond by telling you that their sugar never goes above 120? With Dr. Nathan’s study, you might realistically be able to tell a patient what their “AG” or “average glucose” is. The other pressing importance of this study is that a new, more stable and specific method for standardization of the A1C assay has been developed. Values are lower and units are different than our current A1C assays. Thus, rather than learn a new system for reporting a non-so-helpful number, why not convert it? In the study, approximately 500 patients had their glucose monitored by two methods: continuous glucose monitoring and sever-point daily self monitoring. Many, many glucoses were obtained on these 500 patients and a linear regression analysis was conducted. The table below is the result:
A1C % AG* mg/dl
5 97 (76-120)
6 126 (100-152)
7 154 (123-185)
8 183 (147-217)
9 212 (170-249)
*AG=average glucose
The limitations of the study include the relative lack of representation of minorities, including Asian and African Americans. Nonetheless, it’s thought that the mathematical relationship is sound regardless of ethnicity and age. The importance of this is underscored by its inclusion in the most recent consensus statement on hemoglobin A1C measurement.
Tight Control Is Not Necessary in ICU
September 1, 2008
Risks of Tight Glucose Control in ICU May Outweigh Benefits
Against conventional wisdom, tight glucose control in critically ill patients has not reduced in-hospital death rates. Instead, according to a meta-analysis here, it increases the risk of hypoglycemic episodes.
With data pooled from 27 randomized trials involving 8,315 patients, the relative risk of hospital mortality was 0.93 (95% CI 0.85 to 1.03) for tight glucose control versus usual care, reported Renda Soylemez Wiener, M.D., M.P.H., of the VA Medical Center here, and colleagues in the Aug. 27 issue of the Journal of the American Medical Association.
The American Diabetes Association and several other medical societies have recommended tight glucose control for all critically ill patients, mainly on the basis of a 2001 study that found it reduced hospital mortality among critically ill surgical patients by one-third, said Dr. Wiener and colleagues.
"Subsequent large randomized controlled trials of tight glucose control in medical and mixed medical-surgical ICU settings, however, have failed to replicate this mortality benefit," the researchers said, prompting them to undertake the systematic review.
In an interview, Dr. Wiener said the meta-analysis results warrant a re-evaluation of recommendations of tight glucose control for all ICU patients.
Tight glucose control generally means seeking to keep blood glucose below 150 mg/dL with an insulin infusion during some or all of the ICU stay. Some guidelines, including those endorsed by the ADA, call for glucose levels of 80 to 110 mg/dL.
This study does not surprise me. Achieving tight control while providing intensive care does not have an obvious biologic theory. Of course, if glucose is your focus of attention, then you would be attracted to a glucose theory.
Generally patients in an ICU have so many different problems, that achieving balance seems more important than focusing too deeply on one factor.
Against conventional wisdom, tight glucose control in critically ill patients has not reduced in-hospital death rates. Instead, according to a meta-analysis here, it increases the risk of hypoglycemic episodes.
With data pooled from 27 randomized trials involving 8,315 patients, the relative risk of hospital mortality was 0.93 (95% CI 0.85 to 1.03) for tight glucose control versus usual care, reported Renda Soylemez Wiener, M.D., M.P.H., of the VA Medical Center here, and colleagues in the Aug. 27 issue of the Journal of the American Medical Association.
The American Diabetes Association and several other medical societies have recommended tight glucose control for all critically ill patients, mainly on the basis of a 2001 study that found it reduced hospital mortality among critically ill surgical patients by one-third, said Dr. Wiener and colleagues.
"Subsequent large randomized controlled trials of tight glucose control in medical and mixed medical-surgical ICU settings, however, have failed to replicate this mortality benefit," the researchers said, prompting them to undertake the systematic review.
In an interview, Dr. Wiener said the meta-analysis results warrant a re-evaluation of recommendations of tight glucose control for all ICU patients.
Tight glucose control generally means seeking to keep blood glucose below 150 mg/dL with an insulin infusion during some or all of the ICU stay. Some guidelines, including those endorsed by the ADA, call for glucose levels of 80 to 110 mg/dL.
This study does not surprise me. Achieving tight control while providing intensive care does not have an obvious biologic theory. Of course, if glucose is your focus of attention, then you would be attracted to a glucose theory.
Generally patients in an ICU have so many different problems, that achieving balance seems more important than focusing too deeply on one factor.
HB A1c - Chaos to Harmony!
Haemoglobin A1c (HbA1c) is due to celebrate its 40th birthday. Many people would argue that the clinical studies relating the test to diabetes complications while in its late 20s are likely to be its finest ever achievement. However, this article looks at how HbA1c has matured since then and discusses in detail how its many strengths and idiosyncrasies as a marker of glycaemic risk have, as a 30-something, become more clearly understood.
As HbA1c approaches middle age, this paper also describes how the test appears to be developing a mid-life crisis, as debate over how its results should be expressed seems likely to divide opinion among clinicians for some time to come.
As HbA1c approaches middle age, this paper also describes how the test appears to be developing a mid-life crisis, as debate over how its results should be expressed seems likely to divide opinion among clinicians for some time to come.
ARB plus ACE: ON TARGET
August 19, 2008
Okay, moving on to the next common question, “should I add an ARB to the ACE inhibitor?” Read more..
It’s been shown that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) reduce both proteinuria as well as renal risk (loss of GFR and need for dialysis). What remains unclear, however, is whether a combination of these classes of drugs has an additive effect on renal risk reduction, and whether the effects of ARB and ACE inhibitors are equivalent. Several previous studies have shown that combination therapy reduces proteinuria; however, these trials were limited by their small sample size, short duration of therapy, and did not report on major renal outcomes. The current investigation, the ONTARGET study, published in this week’s Lancet, is a large multi-center, randomized controlled trial that took place over 6 years. Participants were 55 years or older and had established atherosclerotic vascular disease or diabetes with end-organ damage (the baseline mean creatinine was about 83mmol/l). Over 25,000 patients were assigned to ramipril 10 mg daily, telmisartan 80 mg daily, or to a combination of both drugs. The primary outcome was a composite of dialysis, doubling of serum creatinine and death; the secondary outcome was a composite of dialysis and doubling of serum creatinine. The results of this trial may surprise you. Combination therapy reduced proteinuria to a greater degree than either therapy alone. However, both the primary outcome as well as secondary outcome were similar for telmisartan and ramipril but were increased with combination therapy. The study raises interesting questions regarding the relationship between proteinuria and kidney damage and asks if the reduction in proteinuria by itself can be taken as a definitive marker of improved renal function; these questions will no doubt require further investigation. Study limitations include a population that, at baseline, was well-treated with regards to standard cardiovascular therapy and only included a small subgroup with overt diabetic nephropathy. So this population may not represent the majority of patients we treat in our clinic. Overall, this trial suggests that while monotherapy with either an ARB or ACE inhibitor confers similar beneficial effects on major renal outcomes, combination blockade of the renin-angiotensin system may not be the way to go.
It’s been shown that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) reduce both proteinuria as well as renal risk (loss of GFR and need for dialysis). What remains unclear, however, is whether a combination of these classes of drugs has an additive effect on renal risk reduction, and whether the effects of ARB and ACE inhibitors are equivalent. Several previous studies have shown that combination therapy reduces proteinuria; however, these trials were limited by their small sample size, short duration of therapy, and did not report on major renal outcomes. The current investigation, the ONTARGET study, published in this week’s Lancet, is a large multi-center, randomized controlled trial that took place over 6 years. Participants were 55 years or older and had established atherosclerotic vascular disease or diabetes with end-organ damage (the baseline mean creatinine was about 83mmol/l). Over 25,000 patients were assigned to ramipril 10 mg daily, telmisartan 80 mg daily, or to a combination of both drugs. The primary outcome was a composite of dialysis, doubling of serum creatinine and death; the secondary outcome was a composite of dialysis and doubling of serum creatinine. The results of this trial may surprise you. Combination therapy reduced proteinuria to a greater degree than either therapy alone. However, both the primary outcome as well as secondary outcome were similar for telmisartan and ramipril but were increased with combination therapy. The study raises interesting questions regarding the relationship between proteinuria and kidney damage and asks if the reduction in proteinuria by itself can be taken as a definitive marker of improved renal function; these questions will no doubt require further investigation. Study limitations include a population that, at baseline, was well-treated with regards to standard cardiovascular therapy and only included a small subgroup with overt diabetic nephropathy. So this population may not represent the majority of patients we treat in our clinic. Overall, this trial suggests that while monotherapy with either an ARB or ACE inhibitor confers similar beneficial effects on major renal outcomes, combination blockade of the renin-angiotensin system may not be the way to go.
Diabetic Foot Care protocol
August 16, 2008
A simple protocol can assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.
The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report in the August issue of Diabetes Care by Dr. Andrew J. M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group. Read More....
HBA1c is a screening tool for DM
August 11, 2008
HBA1c is an useful tool in the management of DM. It also been a contentious issue whether it can used in screening for DM. This consensus statement is favouring using HBa1c in screening for DM. Read more..
Diagnosing DM...
Intervention vs Responsibility
August 7, 2008
July, 2008 Mayo Clinic Proceedings an article reports the results of a study looking at the value of telemedicine in the management of diabetes. In essence, there were two arms of the study, one with the "usual" management, the other with an endocrinologist available by telemedecine for various problems.
The study found no benefit from having (more or less) instant access to an endocrinologist.
My take on this is that it supports a contention I have about health: It's not about access. It's about patients taking responsibility for their own health. If you are responsible, it becomes your responsibility to learn as much as you can about how to deal with problems, customized to your own situation. So that if you're not doing well, it's your responsibility, not a "failing of the system.Also providing health is not about high tech telemedicine"
The study found no benefit from having (more or less) instant access to an endocrinologist.
My take on this is that it supports a contention I have about health: It's not about access. It's about patients taking responsibility for their own health. If you are responsible, it becomes your responsibility to learn as much as you can about how to deal with problems, customized to your own situation. So that if you're not doing well, it's your responsibility, not a "failing of the system.Also providing health is not about high tech telemedicine"
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